July 2, 2025 • 8 mins
Are our investigations blinded to the functioning and effectiveness of risk controls?
Are our current approaches, and mental models about how safety events occur, defined less by what they unpack and more by what they leave in the dark?
This study unpacks these questions, and evaluates how accident investigators consider, or not, the functioning of risk controls within the context of investigations.
Ref: Dodshon, P., & Hassall, M. E. (2017). Practitioners’ perspectives on incident investigations. Safety science, 93, 187-198.
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Intro/Output "Dark Synth Wave" by ElephantGreen(PixaBay.com)
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
(00:07):
Have you ever looked at a recurring workplace incident and
thought, didn't we investigate this already?
It's a frustrating sense of dejavu, isn't it?
We pour effort into understanding what went wrong,
yet the same kinds of problems keep resurfacing.
This week we're uncovering how if our tools and mental models
are only designed to find specific kinds of problems, like
(00:30):
human error, then that's all we're ever going to find.
This has been called what you look for is what you find.
Therefore, what if our investigations are defined less
by what they find or socially construct is causal, but more by
what they leave in the dark? Good day, everyone.
I'm Ben Hutchinson. This is Safe as a podcast
(00:52):
dedicated to the thrifty analysis of safety, risk and
performance research. Visit safetyinsights.org for
more research. So today's study explored how
incident investigations approachand failed to learn from
incidents, including the types of controls implemented after
investigations. It's titled Practitioners
(01:13):
perspectives on incident investigations, Production and
hassle 2017 in safety science. So what were their methods?
222 survey respondents were included in this data across
mining, construction, transport,postal warehousing and other
industries. They also reviewed incident
(01:33):
investigation manuals and procedures.
Oh hey, future Ben here speakingafter this episode has been
recorded. Now, despite knowing better,
I've used the terms barrier and control synonymously in this
episode, Even though, to be precise, barriers and safeguards
are both types of controls. So controls can be considered a
(01:55):
higher order category. I'll cover more precise
definitions of controls, barriers and safeguards in a
future pod, but using this paper's definition, a control is
an act, object, or system intended to arrest or mitigate
an unwanted event, and that a control must be specifiable,
measurable, and auditable. So what did they find regarding
(02:19):
the identification of controls present at the time of incident?
Just over 50%, around 57% of allindustry survey respondents
indicated that the extent of controls being present at the
time of the incident was considered in their
investigation process. So what this means is that
around 57% of the respondents typically look at the barriers
(02:41):
or controls during the investigation.
So in mining, it was around 50% of the investigations looked at
the barriers, whereas in construction up to 73% of
investigations always consideredwhether the controls were in
place. In transport, postal,
warehousing, it was around 64 1/2%.
This suggests that most organisations are at least
(03:03):
asking the basic question, whereare safeguards in place When
this incident happened for assessment of the effectiveness
of those controls, around 57% ofthe respondents said the control
effectiveness wasn't always considered as part of the
investigation process. Similarly, 60% of the mining and
close to 60% of construction indicated the control
(03:24):
effectiveness wasn't considered in their investigation process.
In contrast, 58% of transport indicated that control
effectiveness was always considered.
So while many check if controls were present, a majority are
failing to ask the crucial follow up question.
Did that control actually work as intended?
Next they looked at absent controls that if they had been
(03:47):
present they might have prevented the incident.
Data across the whole sample indicated that absent controls
wasn't always considered part ofthe current analysis.
It was just over 50%. It was around 57% in mining and
other groups around 59%. So the consideration of control
has been absent at the time of incident wasn't always
considered in construction. It was around 55% indicate that
(04:11):
their investigation always identified absent controls that
if present may have been effective to help prevent or
mitigate the event. This highlights a significant
missed opportunity for learning.Many investigations aren't
asking what else could we have done that wasn't there at the
time. Regarding opportunity to learn,
(04:32):
only around 61% of the investigations focus on
controls, less than 42% focus onevaluating both present and
absolute controls, and just 34% of incidents assess or make
recommendations about enhancing the effectiveness of controls.
This means that while incidents happen, a surprisingly low
percentage of investigations areactually getting to the core of
(04:55):
control effectiveness, which is vital for real learning.
Next, they evaluated the incident manuals.
One finding was that the most frequently used tools by
investigators don't routinely require arresting and mitigation
controls to be identified as part of the incident
investigation process. In practical terms, the very
forms and checklist investigations use often don't
(05:17):
prompt them to think about how to stop or lessen the impact of
an incident. Another interesting finding was
that only 14 of the 24 investigation documents that the
researchers evaluated actually required a description of the
incident or required any human factors considerations or the
sequence of events be part of the investigation.
I think this absence of human facts integration, at least in
(05:40):
the documentation, can be quite telling.
This suggests that foundational elements for understanding the
how and whys of incident and performance, routine and
unroutine performance, and particularly the human element
are often missing from the procedural blueprints of
investigations. They've found very little
reference to the role of mitigation controls, although
(06:01):
prevention controls were more readily recognised.
So investigators were comfortable looking for
prevention controls but very rarely the mitigation controls.
Mitigation is quite a big area of research within the
resilience engineering world. It's also part of failing
safely, that when disaster occurs, how well are we set up
(06:22):
to succeed. They also know that the
initiating events or the initiating hazards was neglected
by over 60% of the organisation.Incident investigation
documentation. This means organisations are
frequently documenting what happened and the contributing
factors, although very narrowly defined, but are often
overlooking how it started or how to contain it after it
(06:45):
begins. So what are some limitations?
For one, it's a survey, so the death of findings are somewhat
limited. It's also unclear how
representative the findings are.They note that while the mining
sample was really large, the other sectors weren't safe.
So what do we make of the findings?
Well, as a study found, some existing investigation
(07:07):
approaches and tools weren't that good at directing people to
understand the context of incidents, or likely by
extension, understanding hazardous work.
Normal daily hazardous work. A focus on barrier performance
also wasn't a big focus in investigations.
This is problematic if your worldview and your approaches
(07:28):
are based around barrier performance, for instance in the
critical control management frameworks or similar
frameworks. As a way to improve the
evaluation of real daily work and the effectiveness of our
barriers, why not try these sorts of questions?
What barriers were expected to be in place and what barriers
were actually in place? Did the barriers perform as
(07:51):
expected? If not, how with the barriers
and their performance specifications even known by
stakeholders? What happened last time this
task was done? With the barriers used well?
How is this task normally done? Or what does good look like?
What's good recognised industry practise?
Or what about some questions from hop or safety tool
(08:13):
approaches? What makes it difficult to apply
these controls? When was the last time you had
to work around the barriers? What's critical for ensuring
safe and reliable work of this kind?
If I gave you $1000 to improve the work, how would you spend
it? That's it on Safe As I'm Ben
(08:33):
Hutchinson. If you've found this useful then
please share, write and review and check out safetyinsights.org
for more research.
Have you ever looked at a recurring workplace incident and
thought, didn't we investigate this already?
It's a frustrating sense of dejavu, isn't it?
We pour effort into understanding what went wrong,
yet the same kinds of problems keep resurfacing.
This week we're uncovering how if our tools and mental models
are only designed to find specific kinds of problems, like
(00:30):
human error, then that's all we're ever going to find.
This has been called what you look for is what you find.
Therefore, what if our investigations are defined less
by what they find or socially construct is causal, but more by
what they leave in the dark? Good day, everyone.
I'm Ben Hutchinson. This is Safe as a podcast
(00:52):
dedicated to the thrifty analysis of safety, risk and
performance research. Visit safetyinsights.org for
more research. So today's study explored how
incident investigations approachand failed to learn from
incidents, including the types of controls implemented after
investigations. It's titled Practitioners
(01:13):
perspectives on incident investigations, Production and
hassle 2017 in safety science. So what were their methods?
222 survey respondents were included in this data across
mining, construction, transport,postal warehousing and other
industries. They also reviewed incident
(01:33):
investigation manuals and procedures.
Oh hey, future Ben here speakingafter this episode has been
recorded. Now, despite knowing better,
I've used the terms barrier and control synonymously in this
episode, Even though, to be precise, barriers and safeguards
are both types of controls. So controls can be considered a
(01:55):
higher order category. I'll cover more precise
definitions of controls, barriers and safeguards in a
future pod, but using this paper's definition, a control is
an act, object, or system intended to arrest or mitigate
an unwanted event, and that a control must be specifiable,
measurable, and auditable. So what did they find regarding
(02:19):
the identification of controls present at the time of incident?
Just over 50%, around 57% of allindustry survey respondents
indicated that the extent of controls being present at the
time of the incident was considered in their
investigation process. So what this means is that
around 57% of the respondents typically look at the barriers
(02:41):
or controls during the investigation.
So in mining, it was around 50% of the investigations looked at
the barriers, whereas in construction up to 73% of
investigations always consideredwhether the controls were in
place. In transport, postal,
warehousing, it was around 64 1/2%.
This suggests that most organisations are at least
(03:03):
asking the basic question, whereare safeguards in place When
this incident happened for assessment of the effectiveness
of those controls, around 57% ofthe respondents said the control
effectiveness wasn't always considered as part of the
investigation process. Similarly, 60% of the mining and
close to 60% of construction indicated the control
(03:24):
effectiveness wasn't considered in their investigation process.
In contrast, 58% of transport indicated that control
effectiveness was always considered.
So while many check if controls were present, a majority are
failing to ask the crucial follow up question.
Did that control actually work as intended?
Next they looked at absent controls that if they had been
(03:47):
present they might have prevented the incident.
Data across the whole sample indicated that absent controls
wasn't always considered part ofthe current analysis.
It was just over 50%. It was around 57% in mining and
other groups around 59%. So the consideration of control
has been absent at the time of incident wasn't always
considered in construction. It was around 55% indicate that
(04:11):
their investigation always identified absent controls that
if present may have been effective to help prevent or
mitigate the event. This highlights a significant
missed opportunity for learning.Many investigations aren't
asking what else could we have done that wasn't there at the
time. Regarding opportunity to learn,
(04:32):
only around 61% of the investigations focus on
controls, less than 42% focus onevaluating both present and
absolute controls, and just 34% of incidents assess or make
recommendations about enhancing the effectiveness of controls.
This means that while incidents happen, a surprisingly low
percentage of investigations areactually getting to the core of
(04:55):
control effectiveness, which is vital for real learning.
Next, they evaluated the incident manuals.
One finding was that the most frequently used tools by
investigators don't routinely require arresting and mitigation
controls to be identified as part of the incident
investigation process. In practical terms, the very
forms and checklist investigations use often don't
(05:17):
prompt them to think about how to stop or lessen the impact of
an incident. Another interesting finding was
that only 14 of the 24 investigation documents that the
researchers evaluated actually required a description of the
incident or required any human factors considerations or the
sequence of events be part of the investigation.
I think this absence of human facts integration, at least in
(05:40):
the documentation, can be quite telling.
This suggests that foundational elements for understanding the
how and whys of incident and performance, routine and
unroutine performance, and particularly the human element
are often missing from the procedural blueprints of
investigations. They've found very little
reference to the role of mitigation controls, although
(06:01):
prevention controls were more readily recognised.
So investigators were comfortable looking for
prevention controls but very rarely the mitigation controls.
Mitigation is quite a big area of research within the
resilience engineering world. It's also part of failing
safely, that when disaster occurs, how well are we set up
(06:22):
to succeed. They also know that the
initiating events or the initiating hazards was neglected
by over 60% of the organisation.Incident investigation
documentation. This means organisations are
frequently documenting what happened and the contributing
factors, although very narrowly defined, but are often
overlooking how it started or how to contain it after it
(06:45):
begins. So what are some limitations?
For one, it's a survey, so the death of findings are somewhat
limited. It's also unclear how
representative the findings are.They note that while the mining
sample was really large, the other sectors weren't safe.
So what do we make of the findings?
Well, as a study found, some existing investigation
(07:07):
approaches and tools weren't that good at directing people to
understand the context of incidents, or likely by
extension, understanding hazardous work.
Normal daily hazardous work. A focus on barrier performance
also wasn't a big focus in investigations.
This is problematic if your worldview and your approaches
(07:28):
are based around barrier performance, for instance in the
critical control management frameworks or similar
frameworks. As a way to improve the
evaluation of real daily work and the effectiveness of our
barriers, why not try these sorts of questions?
What barriers were expected to be in place and what barriers
were actually in place? Did the barriers perform as
(07:51):
expected? If not, how with the barriers
and their performance specifications even known by
stakeholders? What happened last time this
task was done? With the barriers used well?
How is this task normally done? Or what does good look like?
What's good recognised industry practise?
Or what about some questions from hop or safety tool
(08:13):
approaches? What makes it difficult to apply
these controls? When was the last time you had
to work around the barriers? What's critical for ensuring
safe and reliable work of this kind?
If I gave you $1000 to improve the work, how would you spend
it? That's it on Safe As I'm Ben
(08:33):
Hutchinson. If you've found this useful then
please share, write and review and check out safetyinsights.org
for more research.
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